Provider Demographics
NPI:1134342025
Name:KIM, LUIS WOONG-JIN (DDS)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:WOONG-JIN
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 VENTURA AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2122
Mailing Address - Country:US
Mailing Address - Phone:510-526-1757
Mailing Address - Fax:510-526-3397
Practice Address - Street 1:901 VENTURA AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94707-2122
Practice Address - Country:US
Practice Address - Phone:510-526-1757
Practice Address - Fax:510-526-3397
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA412170551OtherTAX I.D.